Jason Y. Huang

EUS-guided portal pressure gradient measurement with a novel 25-gauge needle device versus standard transjugular approach: a comparison animal study

BACKGROUND AND AIMS Portal hypertension (PH) is a serious adverse event of liver cirrhosis. The hepatic venous pressure gradient (HVPG) accurately reflects the degree of PH and is the single best prognostic factor in liver disease. Currently, portal pressure gradient (PPG) measurement is performed at interventional radiology (IR) with a standard transjugular approach requiring radiation and intravenous contrast. The aim of this study was to develop a novel EUS-guided system using a 25G FNA needle and compact manometer to directly measure PPG and to evaluate its performance and clinical feasibility. METHODS Experiments were performed in 3 swine that were under general anesthesia. Manometry was performed in venous (baseline and PH) and arterial (aorta) systems. The PH model was created by rapid Dextran-40 infusion peripherally. Under EUS guidance a 25G FNA needle with attached manometer was used to puncture (transgastric-transhepatic approach) and measure pressures in the portal vein, right hepatic vein (RHV), inferior vena cava (IVC), and aorta. With the IR approach, RHV (free and wedged), IVC, and aorta pressure were measured with an occlusion balloon. Pressure correlation was divided into 3 groups; low pressure (baseline), medium pressure (noncirrhotic portal hypertensive model), and high pressure (arterial). Correlation between the 2 methods of measurement was charted in scatter plots, and the Pearsons correlation coefficient (R) was calculated. RESULTS EUS identification, access, and manometry was successful in all targeted vessels. There was excellent correlation (R, .985-.99) between EUS and IR methods in all pressure ranges. No adverse event occurred. CONCLUSIONS This novel technique of EUS-PPG measurement using a 25G needle and novel manometer was feasible and demonstrated excellent correlation with the standard transjugular method throughout low, medium, and high pressure ranges.

In vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy.

Pancreatic cystic lesions (PCLs) are increasingly identified with the widespread use of imaging modalities. The precise diagnosis of PCLs remains a challenge despite the use of CT, MRI, and EUS-FNA. Confocal laser endomicroscopy (CLE) is a new endoscopic imaging modality that provides real-time, very high magnification images. A smaller CLE probe, which can be passed through a 19-gauge FNA needle, is now available. Needle-based CLE during EUS has recently been examined to evaluate PLCs, and the specific criteria of nCLE for the diagnosis of PLCs have been proposed.

Improvements and innovations in endoscopic ultrasound guided fine needle aspiration

Keywords: Algorithm; Core histology needle; Cytology; Endoscopic ultrasound guided fine needle aspiration fine needle biopsy; Histology

Management of an Accessory Bile Duct Leak Following Pancreaticoduodenectomy: A Novel Approach Utilizing a Percutaneous and Endoscopic Rendezvous

Biliary leaks are uncommon but morbid complications of pancreaticoduodenectomies, which have historically been managed with percutaneous drainage, reoperation, or a combination of both. We report a de novo percutaneous-endoscopic hepaticojejunostomy from an anomalous right hepatic duct injured during pancreaticoduodenectomy to the afferent bowel limb. The percutaneous-endoscopic hepaticojejunostomy was stented to allow for tract formation with successful stent removal after 5.5 months. One year after the creation of the percutaneous-endoscopic hepaticojejunostomy, the patient remains clinically well without evidence of biliary leak or obstruction.

EUS diagnosis and endoscopic management of iatrogenic biliary stent placement into the portal vein.

A 74-year-old man with pancreatic head cancer, treated with chemotherapy, developed relapsing acute pancreatitis. Investigation revealed near-normal liver chemistry test results, an 8-mm common bile duct, and significant pancreatic duct (PD) dilation proximal to the tumor, suggesting that it was the likely cause for the recurrent pancreatitis. Multiple attempts at both transpapillary and EUS-guided transgastric PD cannulation were unsuccessful. A plastic biliary stent was placed during ERCP without symptomatic improvement. The patient was referred to our center for further management. EUS revealed that the previously placed plastic stent was in fact lying within the main portal vein (Fig. 1), without evidence of communication with either the common bile duct or the PD (Video 1, available online at www.giejournal.org). No blood in the region of the stent was evident at duodenoscopy. However, given the risk of bleeding associated with removal of the stent, the portal vein was cannulated by our interventional radiology team by using a US-guided transhepatic approach, thereby facilitating immediate balloon tamponade of the portal vein in the event of bleeding. The stent was then removed endoscopically without incident. ERCP carried out the following day suggested a tight PD stricture in the region of the head-neck